By Rebecca Bowers

EXECUTIVE SUMMARY

A new analysis of a national survey underscores the importance of continued efforts to strengthen practitioner adoption of evidence-based approaches to recommending the HPV vaccine.

  • More than 80% of respondents said that parental refusal or parental influence to delay was their major barrier to immunization. About 30% of parents of children ages 11-12 years who were due for an HPV vaccine refused and 15% hesitated without refusing.
  • Other major barriers included the time required to discuss HPV vaccination with families, a low proportion of adolescents coming in for well visits, and a lack of training in providing a strong recommendation.

What are the barriers to human papillomavirus (HPV) vaccination, and what strategies work best to increase vaccine uptake? A new analysis of a national survey underscores the importance of continued efforts to strengthen practitioner adoption of evidence-based approaches to recommending the HPV vaccine.1

Although more teens are receiving the HPV shot, public health officials say there is room for improvement. Data indicate that a little over half (51%) of adolescents have not received the full series of injections. Location plays an important role: Results of a 2018 analysis indicate that fewer teens in rural areas are getting the HPV shot compared to adolescents in urban areas. Statistics suggest that the number of rural teens who received the first dose of the HPV vaccine lagged 11 percentage points lower than the number in urban areas.2

To perform the current study, investigators examined responses in a sample of pediatricians and nurse practitioners from 19 states who participate in the American Academy of Pediatrics’ (AAP) primary care practice-based research network. As part of the National Institutes of Health’s STOP HPV trial, respondents completed an online, confidential survey that measured office characteristics, standard office procedures for and communication about HPV vaccination, and use of evidence-based strategies such as performance feedback, prompts, reminder-recall, and standing orders.

Results of the survey indicate that all respondents reported more than one barrier to HPV vaccination. More than 80% of respondents said that parental refusal or parental influence to delay was their major barrier to immunization. About 30% (range, 5% to 75%) of parents of children ages 11-12 years who were due for an HPV vaccine refused and 15% (range, 5% to 60%) hesitated without refusing. Other major barriers included the time required to discuss HPV vaccination with families (17% of practitioners), a low proportion of adolescents coming in for well visits (13%), a lack of training in providing a strong recommendation (11%), respondents’ sense that others may think that HPV vaccination can wait (9%), and challenges associated with administering the HPV vaccine during acute or chronic care visits (7%).1

Put Improvements Into Place

Many providers already are implementing strategies to improve HPV vaccination rates, the new analysis indicates. The most commonly reported strategy was use of prompts when HPV vaccination is needed (89%). Respondents also reported that their practices commonly use tools to improve communication about HPV vaccination with parents and adolescents (87%) and they receive performance feedback about HPV vaccination rates (83%). However, just 17% of respondents indicated that their practice uses reminder-recall messages specific to the HPV vaccine.1

Although clinicians are using various strategies to improve HPV vaccine delivery, room for improvement remains. The ongoing STOP HPV trial is evaluating distinct strategies, alone or in combination, to overcome vaccination barriers, says Alexander Fiks, MD, FAAP, MSCE, primary care pediatrician at Children’s Hospital of Philadelphia, AAP Pediatric Research in Office Settings (PROS) Director, associate director of the Center for Pediatric Clinical Effectiveness, and researcher at PolicyLab.

Offer Vaccines Same Day, Same Way

The Centers for Disease Control and Prevention (CDC) continues to recommend routine immunization for girls and boys at age 11 or 12 years; the series can be started at age 9 years. Immunization also is recommended through age 26 years for females and through age 21 years for males. Males 22-26 years of age may be immunized.3 Although the Food and Drug Administration has approved the use of the nine-valent HPV vaccine in women and men 27-45 years of age, the Advisory Committee on Immunization Practices is reviewing further information toward a potential vote on the matter.

The CDC advises that clinicians recommend HPV vaccination in the same way and on the same day that they recommend other vaccines for adolescents.

One way to approach the matter is to say, “Now that your son is 11, he is due for vaccinations today to help protect him from meningitis, HPV cancers, and whooping cough. Do you have any questions?”

Also, remind parents about the needed follow-up shots for their child and ask them to make those appointments before they leave the office.

Explain to parents that the HPV vaccine is important because it prevents infections that can cause cancer. That’s why the immunization series needs to be implemented during the current office visit. If parents question why the vaccine is given at such a young age, the CDC advises clinicians to say that vaccines protect children before they are exposed to a disease. The HPV vaccine is given earlier rather than later so that it can protect children long before they are exposed to the virus.

(The CDC offers helpful information sheets; visit https://bit.ly/2dj9dTt.)

REFERENCES

  1. Wright M, Shone LP, Humiston SG, et al. Pediatric practitioners report using strategies to improve HPV vaccination, yet barriers persist: Results from the National AAP Pediatric Research in Office Settings (PROS) Network. Presented at the 2019 Pediatric Academic Societies Annual Meeting. Baltimore; April 2019.
  2. Walker TY, Elam-Evans LD, Yankey D, et al. National, regional, state, and selected local area vaccination coverage among adolescents aged 13-17 years — United States, 2017. MMWR Morb Mortal Wkly Rep 2018;67:909-917.
  3. Meites E, Kempe A, Markowitz LE. Use of a 2-dose schedule for human papillomavirus vaccination — updated recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep 2016;65:1405-1408.